Canadians are living longer. Unfortunately, our hospitals aren’t ready for them. Canadians over 65 years old use more than 40 per cent of hospital services, a demand that continues to rise. As they age, Canadians hope to stay at home as long as possible. If hospitalization is required, they should expect to go home quickly and safely afterward. Yet many spend weeks to months in a hospital bed, acquiring new health problems and disabilities, only to find themselves among the more than 300,000 Canadians living in nursing homes.
If hospitals are meant for getting well, why does this happen?
Our health-care system was designed in the 1950s and focused on hospitals. Back then, it was about unexpected emergencies, such as pneumonia or injuries. Conditions such as heart attacks had few beneficial treatments, so most patients did not survive very long.
Today, advances in medical science and public health mean that more people survive with conditions that would have killed their grandparents. Conditions that can be treated but not cured are called chronic diseases. The biggest risk factor for chronic diseases is aging. As Canadians get older, they usually acquire not just one but many chronic diseases.
Many older Canadians also develop other age-related problems such as dementia, making simple everyday tasks more difficult. Many lose muscle strength, becoming less active and more disabled.
Over time, the burden of these problems grows, and affected persons become increasingly vulnerable. Simple health challenges such as influenza, nothing more than a nuisance to young people, will incapacitate or kill a vulnerable older person. This vulnerability is called frailty.
The problem is that hospitals remain better suited to care for healthy surgical patients and acute illnesses such as pneumonia. Most are not geared to helping frail seniors cope with acute illnesses or flare-ups of chronic conditions. Frailty is why so many do poorly in senior-unfriendly hospital environments, often becoming more confused and disabled, often irreversibly.
So what can be done?
First, hospitals have to identify vulnerable patients with complex needs so that they can quickly address and minimize complications. Detection requires that the right information be collected efficiently and reliably at the right time.
Ideally, information about complex needs and frailty should be identified early, in all health-care settings, using a common approach. Doing so would mean that important information can be gathered and acted upon even before a hospitalization. Most of the pieces for this approach are in place in Canada, but not in hospitals. Existing hospital documentation systems are bloated and inefficient, collecting some information repetitively but missing other important data.
Yet knowing who’s at risk ensures that patients with mobility issues do not stay bedridden a minute longer than needed. It means that patients with dementia are regularly oriented to place and time and maintained on a stable daily routine. It means aggressive deprescribing programs to get rid of harmful or useless medications. It also means a more efficient health-care system.
An international not-for-profit group of researchers called interRAI has carefully designed and studied instruments for just this purpose. Its assessment tools are already used in home care, nursing homes and mental-health settings across Canada. Unfortunately, they are not used yet in primary care and hospitals, where measuring frailty is typically an afterthought, if done at all.
Along with our colleagues, we recently studied the interRAI Hospital Suite in 10 Canadian hospitals on more than 5,000 older adults, supported by the Canadian Frailty Network. The instruments were easy to use and were able to reliably predict, within 24 hours of hospitalization, which older patients would develop complications in hospital, which ones were at risk of a long hospital stay and which ones were at risk of ending up in a nursing home.
Efforts are already under way to make our hospitals senior friendly, but the lack of systematic assessment in the system overall leaves us all vulnerable as we age. By the time frail patients need hospital care, it is often too late to address their complex needs.
Reliable information is a fundamental requirement to make our health-care system, and especially our hospitals, senior-friendly, allowing better targeting of programs to respond to needs along the entire trajectory of life.
Dr. George Heckman is the Schlegel Research Chair in Geriatric Medicine and an associate professor at the University of Waterloo. Dr. Paul Hébert is a senior scientist at the Centre de recherche du Centre hospitalier de l’Université de Montréal and a full professor in the Department of Medicine of the Université de Montréal.
